How do I use a TIMI risk score in the patient with unstable angina/non-ST elevation myocardial infarction (UA/NSTEMI)?
| ||The thrombolysis in myocardial infarction (TIMI) risk score is used for prognostication and therapeutic decision making in patients with unstable angina/non-ST elevation MI (UA/NSTEMI). |
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HPI: Symptoms of chest pain, dyspnea, diaphoresis.
PMH: Coronary artery disease (CAD), prior myocardial infraction (MI), hypertension (HTN), hyperlipidemia, diabetes.
FH: Premature CAD or MI.
SH: Smoking, alcohol.
Labs: Elevated troponin or CKMB.
| ||ST-segment depression of > 0.5 mm in two or more contiguous ECG leads. |
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UA/NSTEMI = Unstable Angina/Non-ST Elevation MI.
PCI = Refer for Percutaneous Coronary Intervention.
MED-TX = MEDical management = oxygen, aspirin, clopidogrel, nitroglycerine, morphine, metoprolol, unfractionated heparin or enoxaparin (see chapter on initial management of US/NSTEMI).
GP2B3A = GlycoProtein IIb/IIIa (2B3A) inhibitors = use either of these:
Eptifibatide: 180 mcg/kg bolus (maximum 20 mg) IV over 2 minutes, then 2 mcg/kg/min infusion) (maximum 15 mg/hr) for up to 72 hours. Reduce maintenance dose to 1 mcg/kg/min if creatinine clearance <50 mL/min; contraindicated if creatinine clearance <20 mL/min.
Tirofiban: loading infusion: 0.4 mcg/kg/min over 30 minutes, then 0.1 mcg/kg/min infusion for up to 72 hours. Reduce loading and maintenance infusion by 50% in patients with creatinine clearance < 30 mL/min.
HIGHR = HIGH Risk: patients with non-ST-elevated chest pain with one or more of the following characteristics are at a high risk for an adverse cardiovascular event: hemodynamic instability or cardiogenic shock; severe LVD or HF; persistent angina despite medical therapy; new or worsening mitral regurgitation or VSD; or sustained ventricular arrhythmias.
TIMI = TIMI risk score calculated by assigning 1 point for each of the following factors (pneumonic ARCS-ARCS):
Age ≥65 years
Risk factors ≥3 (HTN, DM, H/lipid, active smoker, FamHx premature CAD = myocardial infarction, coronary revascularization, or sudden death <55 years old [father/1st degree male rel] or <65 years old [female/1st deg rel])
CAD (known stenosis > = 50%)
Salicylate, ie, use of aspirin in prior 7 days
Angina Recent and severe (> = 2 anginal episodes in past 24 hours).
Cardiac enzymes elevated (cTnI or CKMB)
ST deviation (new or transient) on ECG > = 0.5 mm
TIMI LOW = TIMI LOW risk: score between 0 and 2.
TIMI HIGH = TIMI HIGH risk: score between 3 and 7.
SRT = Refer patient for stress imaging study to evaluate for inducible ischemia.
SRT-POS = StRess Testing POSitive: imaging study showing significant reversible ischemia, left ventricular dysfunction, ejection fraction < 0.35, or other high risk findings.
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UA/NSTEMI + HIGHR = MED + GP2B3A + PCI
UA/NSTEMI + TIMI LOW = MED + SRT
UA/NSTEMI + TIMI LOW + SRT-POS = MED + PCI
UA/NSTEMI + TIMI HIGH = MED + GP2B3A + PCI
| ||Patients with a high (3–7) TIMI risk score should be referred for PCI and those with low (0–1) and intermediate (2) should be further evaluated for the degree of myocardial ischemia. |
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